Well, that was the conventional wisdom until recently. Ron Winchel, a Manhattan-based psychopharmacologist, says that the psychiatric community is only now coming to realize the potentially disastrous effect of treating bipolar people with SSRIs—and that bipolarity isn’t the easiest thing to recognize. “SSRIs are almost benign, except to the large number of people who at first look to doctors as if they have a unipolar depression, but who in reality have a variant form of one of the bipolar disorders,” he says. “For them, exposure to any antidepressant can actually make them worse, because if you give someone who is potentially bipolar an antidepressant, you can engender more of the ‘high’ side of their disorder. That leads to more depression, because you have accelerated the cycle.”
Winchel calls this “an enormous problem,” because bipolarity can masquerade as regular vanilla depression. “They may never even show mania till after they’ve been exposed to these medications. So what percentage of people who we are blithely handing out SSRIs to, thinking, Oh, there’s no side effect, are actually bipolar?”
But Winchel is also quick to point out another, less frightening, equally surprising medical possibility: “Everyone is always asking me, ‘Is this going to hurt my brain after I’m on it for a long time?’ But no one ever says to me, ‘Is it going to be good for my brain?’ There’s a couple examples—like lithium—where a drug has actually been shown to encourage the growth of healthy brain cells in regions of the brain where there is diminished activity in people with mood syndromes. And we do believe that it is bad for the brain to experience spurts of anxiety, because they are associated with secretions of chemicals that are actually toxic for the brain. So the possibility that some of these drugs that we’re using in psychiatry have neuroprotective effects is real.”
The creative usage and trading of psychopharmaceuticals—the cocktail party as pill bazaar—is what worries the doctors who prescribe the drugs. “There’s a tremendous amount wrong with it,” says Darwin Buschman, a clinical psychopharmacologist affiliated with Mount Sinai, Lenox Hill, Saint Luke’s, and Gracie Square. “Psychostimulants, which include Ritalin and Adderall, and benzodiazepines, which include Xanax and Ativan, are both highly addictive. When one is addicted to benzodiazepines, withdrawal can be life-threatening—particularly with Xanax. Heroin withdrawal is very uncomfortable but not life-threatening; same for coke. But with benzodiazepines, you can die. Period. So I am very careful as to how I prescribe those medications.”
Buschman says that “if you take a benzodiazepine every day for a month, you are addicted,” but he also says that he has patients who take these drugs several times a day and have been doing so for years: “They’re addicted, but it’s what they need. I make sure they don’t run out so they won’t have life-threatening seizures from withdrawal. See, it’s complicated, because while you can die from withdrawal, you cannot overdose on these medications. You can take 5,000 Valium, and you will sleep for a very long time, but you will not die.”
For many doctors, the frustration of working with psychopharmaceuticals is the somewhat arbitrary regulation of the different genres: Some of the least dangerous drugs are the most highly monitored, especially here. New York is the only state in which benzodiazepines are considered a controlled substance, which means they require a triplicate prescription. “Meanwhile, Vicodin isn’t a controlled substance, and it’s infinitely more dangerous than Ativan,” says Buschman.
“What drives me crazy is the people who say ‘Why don’t you try Saint-John’s-wort?’ ” says a high-profile 39-year-old who just started taking her SSRI again after an ill-fated psychopharmaceutical hiatus. “I’m like, what the fuck is that? Because it doesn’t have a stigma and it may not work? Because it’s not regulated? Because I can buy it at some disgusting health-food store? It just amazes me. I was telling this friend: For the past few weeks, I’ve had traditional, horrible depression. I’ve got to go back on meds. And she was like, ‘I don’t know, man.’ I said, ‘Well, I’ve been smoking a lot of pot.’ And she was like, ‘You’ve got a high-pressure job! That’s okay.’ So I said, ‘I smoked a cigarette the other night,’ which for me is a really big deal. ‘Don’t worry about it,’ she said. Then I said, ‘I think I should go back on meds.’ ‘Oh, man,’ she said. ‘You better watch that shit.’ Why?! It’s not like coke or alcohol or drugs, where you wake up the next morning and the problem is ten times worse.”
Ubiquitous lawyer (and Bonfire of the Vanities inspiration) Ed Hayes says, “I just wish the medication had been available to my father and his father. If they had this, they wouldn’t have been drunks. I have very primitive values as to what constitutes masculinity, and I used to think taking medication would mean I wasn’t man enough to handle my problems.” He got over it. “Now I take a simple medication, and the side effects are nothing.”
Before Viagra, the only options open to doctors trying to keep their patients both erect and depression-free were to minimize their dosage, prescribe intermittent “medication holidays,” or supplement an insufficient dose of a given SSRI with Wellbutrin. Even now, when you can buy Viagra over the Internet, some men still opt to work within the new sexual terrain they find their medication has redrawn for them. In certain cases, SSRIs can have the effect of delaying orgasm rather than causing impotence—not necessarily an unwelcome event for all men (or their partners).
“When you first notice the sexual side effects, you’re probably so depressed you just want to get better and you probably don’t feel much like having sex anyway,” says a filmmaker in his early thirties. “But then you start to feel better, and of course you notice. It’s a weird thing . . . I have friends who say they’re into it because it makes them last longer. For me, it’s not a great thing, but for some reason I was like, Yeah, I can live with the fact that my sex life is totally screwed up. But the second I noticed I was getting fat, I was like, Forget this.”
“I take at least 14 pills a day. People are like, ‘Who knows what you could be doing right now if you weren’t medicated?’ It's just crap. What I could be doing is crying in my room.”
Like other prescription drugs circulating through the city, Viagra also has a second life. “Viagra has worked its way into the gays, at least, for recreation,” reports the designer who favors perky stacking boxes stuffed with Xanax for his party favors. “The idea is you’re doing a lot of crystal and a lot of gay party drugs, and it makes it hard to get it up. So the combo plate is you do that and Viagra and it keeps you hard and, um, ups the ante so you don’t have to worry about getting a softy from doing too much K.”
It reminds him, he says wistfully, of his very first prescription party drugs: “My first experience with pills was with downs, to come off disco drugs. It could have been a Valium, and sometimes you’d score with Rohypnol before it became the date-rape drug. That was the best. After you’re through partying, after however long you’ve been up, you want the thing that’ll bring you down the fastest and the hardest, and that’s how the hierarchy was set up.”
Using prescription drugs to work a little harder, sleep a little better, relax a little faster, has become a given in the city’s mainstream. “A friend of mine coined the term cosmetic psychopharmacology,” says Winchel.
“Is this good, or is this bad? is a quasi-philosophical question, an ethical question, more than a medical question. We do enter into this in psychiatry because of the emerging issue of whether or not there are some people we cannot diagnose with a symptom but who seem to benefit from an antidepressant nonetheless.”
A friend of mine who is currently taking Zoloft seems to be getting more agitation from this question than relief from her pills. “If you’re taking something to make your life suck less, then why don’t you just make your life suck less? This is 2003 in an advanced society of which you are one of the most fortunate members! Think if you were a little child in Cambodia who never got education, and compare that to your incredible fucking life! And you’re depressed? How can you be sure it’s not just that you’re a spoiled brat? They say chemicals are not something that you would respond to if you were not depressed, but part of me thinks that’s bullshit.”
It’s true that there are similarities between the way we test meds and the way we used to test witches. If a woman swims, she’s a witch, so you have to kill her; and if she drowns, she’s innocent. But either way, she’s dead. If a person is depressed and a medication affects her mood, then she needs it; if she’s depressed and it doesn’t, she needs a different one. Either way, she’s got to be medicated. “The way that people take it in New York,” says my friend, “I mean, everybody is on something, and that’s stupid! It’s impossible that all highly functioning people are depressed and that they all live in Manhattan.”
I ask what her psychiatrist says about all this.
“She says I’m probably on the wrong drug.”